Payer Relations Specialist

Company: Missouri Primary Care Association ["MPCA"]
Job Title: Payer Relations Specialist
Job Classification: Exempt, Full-Time
Work Schedule: Monday through Friday
Reporting Structure: Vice President of Payer Relations
Eligible for Remote: No
Location: Jefferson City, MO [on-site]

Assists Vice President of Payer Relations with (VPPR) designing and implementing programs, policies and procedures to oversee and solidify all Credentialing requirements and relationship management with health centers and MCO payer contacts. Maintains a lead role in day-to-day delegated Credentialing functions, process improvement, and internal staff audits and maintains efficiencies and overall operational compliance.

• Accurate and timely processing of initial and re-credential applications, meeting verification requirements and standards for MHP to maintain delegated credentialing authority with the MCOs.
• Maintain strong relationships with all payers and health center staff. Establish regular meetings as needed with payers to review and resolve any operational, provider data discrepancies or payment issues. Remain visible and accessible to both FQHCs and payer staff.
• Review and analyze health center member presented claims and provider load discrepancies to identify root cause issues as site billing, payer set up or contract interpretation discrepancies and understand and remain knowledgeable of contract payment terms with ability to identify payment/procedural processing errors and follow up on any discrepancies.
• Collaborate with payer provider relations/claims staff to resolve any operational or procedural issues/patterns with payers or health centers. Coordinate with health center staff to correct any issues.
• Distribute best practices operational information and updates across the MHP network.
• Collaborate closely with Missouri Health Plus team to support patient engagement activities and achievement of various incentives and goals.
• Ensures enrollment access for MHP team is maintained with vendor/source verification electronic sites and portals.
• Support Contracting team during payer negotiations by identifying key areas of payment or procedural problems in an effort to change terms to avoid future recurrences.
• Provide knowledge and support of the delegated credentialing process for the organization.
• Lead the credentialing committee on related processes, have a broad knowledge of Payer and State/Federal regulations, including Medicaid and Medicare, including provider licensure and certification ongoing monitoring as identified in policy and processes.
• Facilitate and conduct required monthly Credentialing Committee meetings with agenda and minutes.
• Support annual payer delegation audits, including key input in the review of audit results against policies and procedures for process improvement.
• Support routine Joint Operations Meetings (JOCs) with payers.
• Lead and maintain functionality and processes of credentialing database to support ongoing functions, monitoring and requirements of the delegated credentialing process.
• Identify payer policy and procedure updates that impact FQHC’s and act as a liaison to relay the relevant information timely.

• High school diploma or equivalent, required. Bachelor’s Degree preferred.
• One to three (1-3) years’ experience within a medical, dental or behavioral health practice.
• One to three (1-3) years’ experience with provider credentialing highly preferred.
• Experience with Missouri based Federally Qualified Health Centers (FQHC), Community Mental Health Center (CMHC) or outpatient primary care practice highly preferred.
• Experience using CAQH Solutions Pro View preferred.
• Familiarity with NCQA and delegated credentialing process preferred.
• Proficiency in all Microsoft Office products required.
• Strong interpersonal communication skills with the ability to effectively communicate, both written and verbal, in a professional manner that supports the ability to establish and maintain effective working relationships across all levels of MPCA and external stakeholders.
• Strong organizational skills, the ability to prioritize, and the ability to coordinate multiple…